A Preliminary Survey of Autism Knowledge and Attitude among Health Care Workers and Pediatricians in Tehran, Iran.

Objective
Autism spectrum disease (ASD) is not a common diagnosis for children presenting with neurodevelopmental delay before 36 months in Iran. Although recent years have witnessed improvements in diagnosis of pediatrics psychological disorders the role of referral system starting with health care workers (HCW) is not clear. Therefore, we aimed to investigate the common concepts about ASD among pediatricians and HCW.


Materials & Methods
Pediatricians were randomly selected from four teaching hospital of Tehran University of Medical Sciences, Tehran, Iran in 2012-13. HCW were randomly selected from 3 urban health care centers in Tehran, Iran. DSM-IV TR criteria for ASD was used to assess knowledge. Participants were asked to rate sixteen statements on beliefs about autism to assess attitude.


Results
Overall, 122 pediatricians and 90 HCWs with mean ± SD age of 36±4.7 yr and 76.4% being female recruited. Pediatricians had significantly higher encounter with autistic patients (18% vs. 10%, P-value=0.06) and parents of autistic child (17% vs. 12%, P-value=0.07). But generally, 209 participants (98.6%) declared that they were familiar with autism. There was no statistically significant difference between study groups in rating DSM-IV TR criteria for ASD as "necessary for diagnosis". Age, gender and working experience, did not differ between pediatricians or HCW answers (all P-values >0.05). Among HCW participants, higher educational level was associated with higher disagreement about "autistic children is schizophrenic" (P=0.01). Moreover, HCW with higher working experience had higher agreement rate with "autistic children needs special education" statement (P= 0.04).


Conclusion
There are still misconceptions about ASD regarding developmental, cognitive and emotional features in both HCW and pediatricians needed to be educated through national program.


Introduction
Autism spectrum disorders (ASD) are a group of neurodevelopmental disorders characterized by impaired social interaction, disabled verbal and non-verbal communication and repetitive behavior (1). These symptoms begin in infancy or early childhood and last for a lifelong (2). Despite great efforts in improving knowledge and researching on this topic in developing countries, there is still a wide gap in many aspects, especially in knowledge and attitudes of different healthcare providers about ASD (3,4). Previous studies are suggestive The survey form consisted of 3 sections: demographics and experience with autism, diagnostic criteria of autism according to DSM IV-TR (9) and sixteen sentences regarding social, emotional, cognitive, treatment and prognostic attitudes toward autism. Participants were asked to rate diagnostic characteristics of autism as "Necessary", "Helpful but Not Necessary" or "Not Helpful". The respondents were informed to rate each statement about their Iran J Child Neurol. Spring 2019 Vol. 13 No. 2 beliefs either as "Agree", not Sure", or "Disagree".
In order to define these sixteen statements on attitudes toward autism, a version of autism survey (10) was used and then it was modified in focus group discussion including 10 experienced specialists in child neurology and child psychiatry.
The internal consistency of this questionnaire was assessed using Cronbach's alpha test and it was 0.8 which provided good reliability.
Categorical variables are expressed as percentages and frequencies and continuous variables are shown as mean ± standard deviation. Categorical and continuous variables were compared using the chi-squared test and the independent student t-test, respectively. All analyses were performed by the two-sided method using SPSS version 22 (Inc., Chicago, IL), and the P-value of <0.05 was set as statistically significant. We assessed the answer of pediatricians and HCW to diagnostic criteria of autism in different age subgroups (<30, 30-40 and >40 yr), gender (male and female), marital status (married, single and divorced) and working experience (10>, 10-20 and >20). None of these factors influenced pediatricians and HCW answers (all P>0.05).  Among HCW participants, higher educational level was associated with higher disagreement about "autistic children is schizophrenic" (P=0.01).  Another aspect needed to be considered is that Moreover, current diagnostic guidelines are all based on researches conducted in developed countries (12,13). Given these differences, applicability of current guidelines and diagnostic tools should be tested across cultures and social classes of developing countries.

Three
One of the hallmarks of ASD diagnosis is that symptoms initiate before 36 months of age.
However, in both groups of HCWs and pediatricians lower than 50% of participants considered this criterion to be necessary to diagnose the disease.
Parents of children with ASD had noticed that there might be "something wrong" with their children in age of fifteen to nineteen months old but as they referred to health professionals, they were reassured to have normal children (14,15). This is also the problem reported in a study from Pakistan (4). Delay in neurocognitive developmental milestones especially speech is the initial presentation in many known cases of ASD.
On the other hand, nonspecific symptoms may be seen in normal patients as well. This lack of knowledge about characteristic presentations and differential diagnosis postpone timely diagnosis. All authors agreed to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.